2 Renal dialysis Radiation and chemotherapy Post-stabilization services $50 deductible for families with incomes between 186% - 200% of FPL Professional (Physician/Physician Extender) Unlimited. Includes: American Academy of Pediatrics recommended wellchild exams and preventive health services (including but not limited to vision and hearing screening and immunizations) Physician office visits Laboratory, x-rays, imaging and pathology services and professional interpretation Medications and materials administered in physician s office Allergy testing Professional component (in/outpatient) of surgical services, including: Surgeons and assistant surgeons for major and minor surgical procedures including appropriate follow-up care Administration of anesthesia by physician (other than surgeon) or CRNA Second surgical opinions Same-day surgery performed in a hospital without an over-night stay Invasive diagnostic procedures such as endoscopic examinations Does not cover infertility treatments and prostate and mammography screening Does not cover reproductive services other than prenatal care, labor and delivery, and care related to diseases, illnesses, or abnormalities related to the reproductive system Copayments required for members above 100% of FPL except for well-child visits, well-baby visits, and immunizations Prescription Drugs Includes unlimited drugs prescribed for the medical treatment of illness or injuries HMO may use a closed formulary but must provide a 2

3 process for consideration of drugs outside the formulary when medically necessary Excludes contraceptive medications prescribed only for the purpose of primary and preventive reproductive health care Copayments required for members above 100% of FPL Inpatient Mental Health Includes services furnished in a free-standing psychiatric hospital, psychiatric units of general acute care hospitals and state-operated mental hospitals.: 45 days annual limit inpatient 25 days of the inpatient benefit can be converted to residential treatment, therapeutic foster care or other 24-hour therapeutically planned and structured services or subacute outpatient (partial hospitalization or rehabilitative day treatment) mental health services on the basis of financial equivalence against the inpatient per diem cost. Twenty of the inpatient days must be held in reserve for inpatient use only. Outpatient Mental Health Outpatient services may require prior authorization but do not require physician prescription. Medication management visits do not count against the outpatient visit limit. 60 days annual limit rehabilitative day treatment 60 outpatient visits annual limit for crisis stabilization, evaluation and treatment, including office, school, in-home and outpatient hospital based services (includes, but is not limited to, serious mental illness) Limitations/Exclusions 60 rehabilitative day treatment days can be converted to outpatient visits on the basis of financial equivalence against the day treatment per diem cost. Durable Medical Equipment (DME), Prosthetic Devices and Disposable Medical Supplies Includes equipment, devices and supplies that are medically indicated to assist in the treatment of a medical condition, including but not limited to: : Orthotic braces and orthotics Prosthetic devices such as artificial eyes and limbs, braces, hearing aides, and eyeglasses Other artificial aides including surgical implants Disposable medical supplies 3

4 $20,000 annual limit for DME, prosthetics, devices and disposable medical supplies (diabetic supplies and equipment are not counted against this cap) Authorization for more than one pair of eyeglasses annually and/or for contact lenses when medically necessary. Home and Community Health Includes therapies provided in the home and community: Speech, physical and occupational therapy Home infusion Respiratory therapy Visits for private duty nursing Skilled nursing visits Does not include custodial care Inpatient/Residential and Outpatient Substance Abuse Treatment Residential rehabilitation and outpatient substance abuse treatment services do not require physician prescription. Prevention and intervention services, screening, assessment and referral for chemical dependency disorders, hospital inpatient/residential services 14 days annual limit detox/crisis stabilization 24 hour residential rehabilitation program up to 60 days per episode. 30 days must be held in reserve but 30 days (in addition to benefits below) may be converted to 60 days partial hospitalization, 90 days intensive outpatient rehabilitation or 90 days of outpatient services Maximum of three inpatient/residential episodes per lifetime Intensive outpatient program (up to 12 weeks per episode) Outpatient services (up to six months per episode) Maximum of three outpatient episodes per lifetime of nonemergent services Case Management for Children with Complex Special Health Care Needs Covered services are beyond the scope normally provided and include (Refer to Section X, Item B): Outreach and informing 4

6 Member copayments are required for emergency room visits Emergency ground transportation Professional Vision Examination by an optometrist or ophthalmologist to determine the need for and prescription for corrective lenses and frames One routine eye exam annually Transplants All non-experimental human organ and tissue transplants and all forms of bone marrow transplants and peripheral stem cell transplants, including donor medical expenses Does not cover donor non-medical expenses May require prior authorization Chiropractic Covered services do not require physician prescription and include: Spinal subluxation as indicated by x-rays Maximum 12 treatments annually May require prior authorization for additional treatments Non-Emergency Transportation May be included as a value added service in areas without accessible public transportation when the family cannot provide the transportation 6

Summary of Services and Cost Shares This summary does not describe benefits. For the description of a benefit, including any limitations or exclusions, please refer to the identical heading in the Benefits

and Wisconsin Covered Services Comparison Chart The covered services information in the following chart is provided as general information. Providers should refer to their service-specific publications

WHO IS COVERED Requires both Medicare A & B enrollment. Type of Coverage Offered Single only Single only MEDICAL NECESSITY Pre-Certification Requirement None None Medical Benefit Management Program Not

MICHIGAN CATHOLIC CONFERENCE January 2015 Benefit Summary This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations

SU Pro ( and ) Annual Deductible 1 Coinsurance Cost Sharing Definitions $200 per individual with a maximum of $400 for a family 5% of allowable amount for inpatient hospitalization - or - 50% of allowable

WHO IS COVERED Requires Covered Member to be Enrolled in Both Medicare Parts A & B Type of Coverage Offered Single only Single only MEDICAL NECESSITY Pre-Certification Requirement Not Applicable Not Applicable

You may receive covered services that are performed, prescribed or directed by a participating provider. As an Enrollee, you must receive your healthcare services from a participating PCP or medical provider.

DRAKE UNIVERSITY HEALTH PLAN Effective Date: 1/1/2015 This is a general description of coverage. It is not a statement of contract. Actual coverage is subject to terms and the conditions specified in the

PPO Schedule of Payments (Maryland Small Group) National PPO 1000 The benefits outlined in this Schedule are in addition to the benefits offered under Coventry Health & Life Insurance Company Small Employer

AVMED POS PLAN This Schedule of Benefits reflects the higher provider and prescription copays for 2015. This is not a contract, it s a summary of the plan highlights and is subject to change. For specific

2015 Medical Plan Summary AVMED POS PLAN This Schedule of Benefits reflects the higher provider and prescription copayments for 2015. This is not a contract, it s a summary of the plan highlights and is

Summary of Benefits Community Advantage (HMO) January 1, 2015 - December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list

[2015] SUMMARY OF BENEFITS H1189_2015SB Section I You have choices in your health care One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare

MyHPN Solutions HMO Silver 4 Attachment A Schedule Calendar Year Deductible (CYD): $2,250 of EME per Member and $4,500 of EME per family. The Calendar Year Out of Pocket Maximum includes the CYD and is

Who is eligible to enroll in the Plan? All State of Michigan Employees who reside in the coverage area determined by zip code. All State of Michigan Employees who reside in the coverage area determined

Coverage For: Self Plan Type: HMO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.westernhealth.com or

An individual PPO health plan from Blue Cross Blue Shield of Michigan. You will have a broad choice of doctors and hospitals within Blue Cross Blue Shield of Michigan s unsurpassed statewide PPO network

Alternative Benefit Plan (ABP) ABP Cost-Sharing & Comparison to Standard Medicaid Services Most adults who qualify for the Medicaid category known as the Other Adult Group receive services under the New

University of Michigan Group: 007005187-0000, 0001 Comprehensive Major Medical (CMM) Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only a general overview of your benefits.

2014 2015 Medical Plan Summary for International Students Translation Services If you need an interpreter to help with oral translation services, you may contact the LifeWise Customer Service team at 1-800-971-1491

BENEFIT IN NETWORK OUT OF NETWORK This plan is intended to comply with the federal Patient Protection and Affordable Care Act. Provisions are subject to change as additional regulatory guidance becomes

CSAC/EIA Health Small Group Access+ HMO 15-0 Inpatient Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthoptions.org or by calling 1-855-624-6463. Important

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.gundersenhealthplan.org or by calling 1-800-897-1923.

Schedule of s HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS ID: MD0000003378_ X Please Note: In this plan, Members have access to network benefits only from the providers in the Harvard Pilgrim-Lahey

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://www.cs.ny.gov/employee-benefits or by calling 1-877-7-NYSHIP

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.trilliumchp.com or by calling 1-800-910-3906. Important

Health Alliance Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2014-12/31/2014 Coverage for: Individual Family Plan Type: HMO This is only a summary.

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.uhs.wisc.edu/ship or by calling 1-866-796-7899. Important

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.thehealthplan.com or by calling 1-800-447-4000. Important

January, 205 December 3, 205 Summary of Benefits H3928-00 80.06.360.-LA Y0022_205_H3928_00_LA Accepted 9/204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of what we

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.landoflincolnhealth.org or by calling 1-844-FHN-4YOU.

33653ME010030915 Community Balance H S A Coverage Period: [1/1/2016-12/31/2016] This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy

19304NH01000010915-01 Community Basic H S A (Bronze) Coverage Period: [1/1/2016-12/31/2016] This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms

Aetna HDHP What is the overall deductible? Do I need a referral to see a specialist? Are there this plan doesn't cover? Yes. This is only a summary. If you want more details about your coverage and costs,

: VIVA HEALTH Access Plan Coverage Period: 01/01/2015 12/31/2015 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document

2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3952 Y0041_H3952_KS_15_18734 Accepted 09/01/2014 Section I: Introduction to Summary of Benefits You have choices about how

Coverage Period: Beginning on or after 1/1/2016 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://www.capbluecross.com/sbcsia

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at MedMutual.com/SBC or by calling 800.540.2583. Important Questions

UnitedHealthcare Life Ins Co: Platinum Copay Select Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.etf.wi.gov or by calling 1-877-533-5020. Important Questions

SECTION A. Summary of Benefits LW-V, 10/09 This Summary is part of your Benefit Handbook. It states the Cost Sharing amounts that you must pay for Covered Benefits and some important limitations on your